1. Pathway Model: A Tool to Measure Outcomes Target Population Engage those at greatest risk Assure connection to evidence-based intervention Measureable Outcome 1 - Find 2 - Treat 3 - Measure

2. Model - Health Care Delivery System

3. At risk - less likely to connect to prevention and early treatment today than decade ago. The health care budget has nearly tripled in that time 5% of Population = 50% of the cost and the greatest weight of our health disparity Why focus on Those at risk?

4. HealthSocial From the clients perspective social issues are as important as health issues and both must be addressed

5. We have the evidence based interventions 5

6. 6 Our current health care system does not assure that those at risk Receive / Connect to the critical packages of prevention and early treatment Where is Our Delivery System?

7. Identify/enroll at risk Care Coordination Evidence based Intervention Final Outcome $ $ $

8. One client has many issues that require multiple Pathways More Than One Pathway Needed

9. Pathways Community HUB A Regional Delivery System Across Health and Social Service

10. Healthy People 2010 Goal – 5% Low Birth Weight within CHAP as a Single Agency Using Pathways Low Birth Weight Across the Region - Implementing a Pathways Community Hub

11. Richland County Community HUB It’s a systems issue.... Do we serve the most at-risk? Why should we? 5% of population uses 50% of health care resources Most at-risk are often the hardest to serve  no incentive to serve them. Access for all (insured and un-insured) has gotten worse over the past 10 years

12. Pregnant Client at-risk: Her issues cross multiple agencies that function as silos: Health care Insurance Housing Education / employment Mental health... and no one is measuring the system  only the individual programs

13. Women at-risk of a poor birth outcome: Richland County, OH 4 years of data from vital statistics – Low Birth Weight births Areas of High Risk

14. Where services were going.... Services delivered in Low Risk Areas

15. Community HUB Primary Health Home State funded outreach program State funded outreach program Schools Health Department County agency Mental Health Hospital Community based agency One Care Coordinator  One Outcome (Pathway) NO DUPLICATION MEASUREABLE RESULTS, TIED TO FUNDING Central Registration – Agencies as a Team

16. Regional Team of 7 Care Coordination Agencies Increasing Connection to Care for At Risk Pregnant Women

17. Partnerships Necessary FUNDERS: Pay for the Packages Federal (HRSA) State Local –Ada Ford Fund & other private foundations –County Job & Family Services –Medicaid Managed Care –State Health Department –United Way Delivers the Packages: CARE COORDINATORS Identify & Track the Packages: Agencies Providers Clinics Hospital Mental Health Community based organizations Schools Aging Faith based organizations Community HUB – Monitors the Whole System

18. Problem Statement: 1. Do we care about serving those in the community most at-risk for poor health and social outcomes? 2. If we do care  then we do not have the infrastructure in place within the community to measure this. Solution: Development of a Community HUB: 1.Single point of registry in the community. 2.Common metrics across providers and agencies. 3.Payment linked to measureable outcomes. Results: 1.No duplication 2.More efficient and effective use of community resources 3.Improvement in disparities – health and social 4.Cost savings Review